Tzu Chi Medical Journal 23 (2011) 60e62 Contents lists available at ScienceDirect Tzu Chi Medical Journal journal homepage: www.tzuchimedjnl.com Case Report Lateral sinus thrombosis as a complication of a superior rectus muscle abscess caused by Gemella morbillorum bacteremia Shih-Wen Wang a, Fu-Zong Xiao b, Chorng-Jang Lay a,c, Chun-Lung Wang a,c, Chen-Chi Tsai a,c,* a School of Medicine, Tzu Chi University, Hualien, Taiwan b Department of Radiology, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan c Division of Infectious Diseases, Department of Medicine, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan article info abstract Article history: Gemella morbillorum is found in normal oral flora and is a potential bloodborne pathogen. We present Received 25 June 2010 a case of G morbillorum bacteremia with lateral sinus thrombosis complicated by a superior rectus muscle Received in revised form abscess. The patient was successfully treated with adequate antibiotics without surgery or anti- 9 September 2010 coagulation therapy. The pathogen has not been previously reported to be associated with dural Accepted 1 October 2010 thrombosis. The aim of this report was to draw attention to this little-known pathogen that causes dural thrombosis. Keywords: Copyright Ó 2011, Buddhist Compassion Relief Tzu Chi Foundation. Published by Elsevier Taiwan LLC. All Bacteremia Gemella morbillorum rights reserved. Lateral sinus thrombosis 1. Introduction venous sinuses. We, herein, report a case of septic thrombosis of the dural venous sinuses complicated by a superior rectus muscle Gemella morbillorum is a Gram-positive, catalase-negative, abscess that was caused by G morbillorum bacteremia. facultatively anaerobic coccus. It was previously named Diplococcus morbillorum, Peptococcus morbillorum, Peptostreptococcus morbillo- 2. Case report rum,orStreptococcus morbillorum. This organism was eventually transferred from the genus Streptococcus to the genus Gemella in An 83-year-old woman with a history of hypertension for 20 1988 on the basis of its biomolecular features and physiological years was admitted because of headache and bilateral eyelid properties [1]. Several types of infections have been identified as swelling that had been present for 1 week. She had been able to being caused by these pathogens, including bacteremia, infective walk and perform activities of daily living until 1 week ago. She endocarditis, pericarditis, arthritis, pleural empyema, lung abscess, then developed intermittent headaches, dizziness, and general peritonitis, pneumonia, Ludwig’s angina, septic shock, spondylo- weakness. Bilateral eyelid swelling was noted by her family, and discitis, brain abscess, and soft tissue infection [2e12]. she had attended a local clinic 1 day before admission, where Thrombosis of the dural venous sinuses is generally described as analgesic agents were injected without improvement. No fever, occurring because of an infective etiology; however, there have been cough, rhinorrhea, nausea, vomiting, diarrhea, dysphagia, or reports of it developing after nasal surgery or trauma [13].This dysuria was noted. She did not have a history of dental procedure or disorder was frequently encountered in the pre-antibiotic era but trauma in the last 3 months. The symptoms persisted, and she then has become rarer because of the widespread use of antibiotics for the visited our emergency department. treatment of oropharyngeal infections [14]. The common organisms Physical examination revealed a temperature of 37C, a blood associated with septic thrombosis of dural sinuses are Staphylococcus pressure of 110/90 mmHg, a respiratory rate of 18 cycles/min, and aureus, Streptococcus pneumoniae,otherStreptococci,Gram-negative a heart rate of 105 beats/min. She was drowsy but arousable. A head bacilli, and anaerobes [15,16]. Gemella morbillorum had not been and neck examination revealed bilateral eyelid swelling accompa- reported as a pathogen that causes septic thrombosis of the dural nied by chemosis. Her right eye could not move in the upper right direction. Pulmonary and cardiac examinations revealed no abnormality. A peripheral hemogram revealed a leukocyte count of * Corresponding author. Division of Infectious Disease, Department of Medicine, 32.3 Â 103/mL with 25% band form, a hemoglobin level of 12.3 g/dL, Buddhist Dalin Tzu Chi General Hospital, 2, Min-Sheng Road, Dalin, Chiayi, Taiwan. Â 3 m Tel.: þ886 5 2648000; fax: þ886 5 2648999. and a platelet count of 215 10 / L. Serum aspartate aminotrans- E-mail address: [email protected] (C.-C. Tsai). ferase level was 38 IU/L; urea nitrogen, 36 mg/dL; creatinine, 1016-3190/$ e see front matter Copyright Ó 2011, Buddhist Compassion Relief Tzu Chi Foundation. Published by Elsevier Taiwan LLC. All rights reserved. doi:10.1016/j.tcmj.2011.01.008 S.-W. Wang et al. / Tzu Chi Medical Journal 23 (2011) 60e62 61 1.6 mg/dL; and C-reactive protein, 32.65 mg/dL. Urinalysis and changed to intravenous penicillin (Y F Chemical Corp., Taiwan) chest film revealed no abnormalities. Brain computed tomography 3 MU every 4 hours and clindamycin (Nang Kuang Pharmaceutical showed paranasal, ethmoid, and sphenoid sinusitis. Co., Ltd., Taiwan) 600 mg every 8 hours on the seventh day at She was admitted to our ward and treated by intravenous cef- hospital. Her eyelid swelling and headache subsided gradually but triaxone (Roche Ltd., Switzerland) 2 g every 12 hours and metroni- diplopia persisted because of impaired abduction of the right eye. dazole (China Chemical & Pharmaceutical Co., Lt., Taiwan) 500 mg Aspiration of the superior rectus muscle abscess was arranged but every 8 hours. Nonetheless, her headaches, dizziness, and diplopia not performed because of her family’s hesitancy with respect to the persisted, and a blood culture yielded Gram-positive cocci. Antibi- risk of surgery. Antibiotics were continued. Her diplopia improved otics were changed to intravenous vancomycin (Gentle Pharma- gradually. After a 24-day course of intravenous antibiotics, she was ceutical Corporation Kashin Medicines Co, Ltd., Taiwan) 1 g everyday discharged and was maintained on oral amoxicillin/clavulanic acid and piperacillinetazobactam (Wyeth-Ayerst Ltd., Taiwan Branch, (Smithkline Beecham plc, United Kingdom) 875/125 mg every 12 Taiwan) 2.25 g every 6 hours on the second day at hospital. Magnetic hours for 2 months. She had remained well when examined on her resonance imaging with contrast enhancement revealed fluid follow-up visit 3 months later. collection in the right paranasal sinus, clivus, right sphenoid sinus, and right ethmoid sinus, and abnormal fluid collection in the right 3. Discussion superior rectus muscles. A magnetic resonance venogram showed a filling defect of the right internal jugular vein, right transverse The cerebral veins and venous sinuses have no valves, and sinus, and right sigmoid sinus. Three-dimensional reconstruction of therefore, blood within them can flow in either direction depend- the venogram indicated an obstruction of the right transverse sinus ing on the pressure gradient. Uncontrolled infections of the facial and right internal jugular vein (Fig. 1). area frequently led to septic thrombosis of the intracranial venous Two sets of blood cultures yielded Gram-positive cocci. After 48- sinuses in the pre-antibiotic era. Three types of dural venous sinus hour incubation, an a-hemolytic organism that grew on sheep thrombosis have been established by anatomy, and they are blood agar was cultured and was characterized as catalase negative cavernous sinus thrombosis, lateral sinus thrombosis (LST), and and nonebile soluble. The biochemical identification system Vitek superior sagittal sinus thrombosis [15]. The thromboses in lateral II (bioMérieux, Marcy l'Etoile, France) identified the organism as and transverse sinuses in our case belonged to the LST group. G morbillorum. The strain was susceptible to penicillin, amoxicillin, LST is a rare but feared intracranial complication of otitis mediaand piperacillin, and clindamycin. The patient’s antibiotics were associated mastoiditis. Modern reported mortality rates are lower Fig. 1. Magnetic resonance T1-weighted imaging after gadolinium enhancement showed fluid collection in right paranasal sinus, clivus (A), right sphenoid sinus, and right ethmoid sinus (B), and abnormal fluid collection in right superior rectus muscles (B). Magnetic resonance venogram showed filling defect in right internal jugular vein (C), right transverse sinus (D), and right sigmoid sinus (E). Reconstructive venogram showed occlusion of right transverse sinus and right internal jugular vein (F). 62 S.-W. Wang et al. / Tzu Chi Medical Journal 23 (2011) 60e62 than earlier ones but still range from 2% to 10% [17e20].Thepatho- persistent fevers despite appropriate surgical intervention [28]. genesis seems to be almost exclusively because of the spread of Although the clot burden extended to the internal jugular vein and infection to the lateral and sigmoid sinuses from the mastoid air cells, transverse sinus in our case, there were no embolic events, either through the emissary vein or by direct invasion. LST most persistent fever, or neurological changes associated with the LST. frequently occurs as a complication of ear infection [15e21].Our Antibiotics alone without anticoagulation appeared to be sufficient patient did not have any of the typical signs of otitis media, such as to treat the LST under these conditions. otalgiaand otorrhea, and therefore, thiscannot beconsidered to be the